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General NPI Number Information
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NPI Number | 1023725041
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Entity Type | Individual
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Provider Name | SAMUEL VLADIMIR KISELMAN
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Gender | Male
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Dates
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Enumeration Date | 10/31/2022
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Last Update Date | 10/31/2022
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Provider Practice Location Address
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Address Line | 4101 SE 192ND AVE # 101
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City | VANCOUVER
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State | WA
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Zip | 98683-1471
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Country | US
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Telephone | 360-605-1881
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Fax |
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Provider Business Mailing Address
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Address Line | 4619 NE 112TH AVE
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City | VANCOUVER
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State | WA
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Zip | 98682-6698
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Country | US
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Telephone | 206-554-9058
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | WDL546BCD03B
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License Number State | WA
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